Since January 1, 2017, the Centers for Medicare & Medicaid Services (CMS) has authorized payment for CPT codes 99358 – 99359 for prolonged services non-face-to-face (F2F). When used correctly, this is a significant reimbursement opportunity for Home-Based Primary Care (HBPC) providers.

The CMS national payment rate for 99358 is $113.52 (the rate for 99359 is $54.78) with a Relative Value Unit (wRVU) of 2.10. This provides payment for the extensive medical management that occurs outside of the F2F visit. Although the use of these codes offers financial benefits, many practices continue to have concerns and/or questions regarding the services, leading to these codes being underutilized.

To help you receive the appropriate amount of reimbursement for the work your providers are doing under these codes, review the below requirements and apply them when appropriate:

  • The provider’s work is payable for both the office and outpatient setting (e.g., home or domiciliary visits, hospital, and nursing facility).
  • Time guidelines:
    • The billing physician or other qualified health care professional must spend a minimum of 31 minutes beyond the typical F2F time associated with the service as time directly related to an Evaluation and Management (E/M) F2F visit.
    • This time must be beyond the usual service time a provider would spend with the patient.
    • The provider must document why the service went above the normal time and effort.
    • The non-face-to-face time may occur on the same or a different date (i.e., before or after the visit) as the E/M F2F visit, if the documentation references the primary service it’s related to.
    • The exact amount of time spent must be documented in the medical record; the time does not need to be continuous (e.g., 20 mins in the AM and 15 mins in the PM), however, it must occur on the same calendar date.
    • The total time cannot be a compilation of times added together from various calendar days.
    • The service provided cannot be reported for time spent in non-face-to-face care described by more specific codes having no upper time limit within the CPT code set.
    • CMS notes that, while the typical CPT threshold times are not required for billing prolonged services, it is expected that only time spent in excess of these times is to be reported under CPT codes 99358-99359.
    • Per the CMS Claims Processing Manual, start and stop times are required for documented time (Page 83 of the manual: The start and end times of the visit shall be documented in the medical record along with the date of service).

In summary, your documentation should include start and stop times that show a minimum of 31 minutes spent on time directly related to an E/M visit. If the time occurred on a different date than the visit, you must reference the date of the F2F service and include a brief description of how that time was spent (e.g., nature or topic of what was reviewed or discussed).

In addition, CPT codes 99358-99359 cannot be reported during the same service period as the following due to similarity in service. As of 2020, however, prolonged services will be unbundled with transitional care management services, meaning they can be reported within the same calendar month:

  • Chronic Care Management (CCM)
  • Transitional Care Management (TCM)
  • Care Plan Oversight (CPO)
  • Anticoagulation Management
  • Medical Team Conferences
  • Online Medical Evaluations

For additional reference, the National Government Services (NGS) offers the following examples of appropriate uses of CPT codes 99358-99359:

  • Extensive medical record review directly related to an F2F encounter
  • Extensive telephone time with the patient and/or family that directly relates to an E/M encounter
  • Family/caregiver meeting, even without patient involvement but directly related to an F2F encounter

While these guidelines may seem challenging, you can tackle them by creating a Macro within your Electronic Health Record (EHR) that your providers can use for documentation purposes. In addition, you can create a back-end charge review rule to ensure the work does not get billed out during the same calendar month as other bundled services.

The time you invest in understanding these guidelines will assist in exponentially growing financial benefits for your practice.

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9905.pdf